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Saturday, February 7, 2009

Universal Health Insurance or Universal Quality Health Care?

Jonathan Gruber, an MIT economist, has a piece in the January 29 issue of the New England Journal of Medicine entitled “Universal Health Insurance Coverage or Economic Relief – A False Choice”.[1] He clearly delineates the case for proceeding with health reform even in – perhaps especially in – these difficult economic times. He argues that rather than “Universal coverage…” being “…a luxury that we must do without in order to make way for other programs that will stimulate the economy”, that it is not only necessary for people’s health, but will in itself stimulate the economy. He suggests that “broad subsidies that make affordable health insurance available to lower-income families would improve not only the health of these families but the health of our economy, by freeing up funds that the families could spend on other consumer goods.”

Other ways it would stimulate the economy include elimination of “job lock”, the common (he states as much as 25%) circumstance in which people are afraid to leave their jobs, even for new and exciting opportunities (and “the most productive positions”), for fear of losing their health insurance, especially when they have pre-existing conditions. He notes that universal health insurance, if it required electronic health records and other methods of information sharing, would also be a great economic stimulus to the information technology industry. He cites the “white paper” issued by Sen. Baucus (D-MT), calling for dramatic investment in primary and preventive care, and the creation of the “patient centered medical home”, both things I have written about and strongly supported in previous posts. Finally, he discusses how having universal health coverage will allow us to focus on controlling spiraling health care costs: “I have witnessed this effect firsthand in Massachusetts, where for years our advocacy community focused exclusively on expanding coverage for medical expenditures and therefore opposed most initiatives that might have put that goals at risk, even those that might have meant controlling costs. Since Massachusetts passed its universal-coverage plan, this powerful advocacy community has shifted its attention to controlling costs as a means of preserving the program’s affordability to the state.”

These are all important points, and Dr. Gruber’s case for moving ahead with health reform as expeditiously as possible is on target. However, his position is inadequate, incomplete, and likely doomed to not achieve the goals he articulates because of several major misconceptions or issues insufficiently thought through. While his endorsing primary care and prevention is great, he goes on to state that “Such an approach would shift the focus of the health care system from specialists to preventive care practitioners with much lower barriers to entry, such as those for nurse practitioners and registered nurses.” This is a deeply flawed concept on several levels.

First, there is a major qualitative distinction between the skill set and practice role of registered nurses and nurse practitioners. Glossing over this is the most obvious indication of a fantastic lack of understanding of medical care and health care delivery. As documented by my guest author Robert Bowman in the January 15 entry “Ten Biggest Myths Regarding Primary Care in the Future”, nurse practitioners do not provide enough “standard primary care years” of practice to meet our needs, and without a more comprehensive approach to addressing the primary care/subspecialist imbalance, NPs (and physicians’ assistants) are likely to continue to move from primary care into higher-paying positions in subspecialty care. This leads to the third flaw, the idea that we can increase the number of practitioners in the primary care / preventive specialties without limiting the production of subspecialists. These “partialists” are paid an enormous amount for caring for “pieces” of people and are paid especially well for providing procedures, many of which involve mainly psychomotor rather than cognitive skill. Not every procedure is “brain surgery”; many are routine activities that could easily be done by technicians trained at a community college level (as are X-ray and laboratory technicians). However, they are so highly reimbursed that there is great pressure to 1) keep the entry level high (physician subspecialist), and 2) increase the volume of these procedures – many studies have demonstrated that in the weird inverted “market” of medical care, it is the availability of subspecialists and technology that drive demand rather than vice versa. Only by dramatically decreasing the financial incentives to enter subspecialties while increasing incentives to enter primary care can we reach the proper ratio of primary care to subspecialty care providers. (If our goal is to have 50% primary care providers, while we currently have 30% or less, we will need to have a much greater than 50% primary care provider output or it will be more than 30 years before we achieve this goal.)

Finally, Gruber’s flip comment plays directly into the idea, entrenched in the medical profession and medical trainees, that subspecialties, because they earn so much more, require greater skill and intelligence and thus merit higher “barriers to entry” than primary care. This is absolutely not so. In addition to the issue of high reimbursement for relatively simple psychomotor procedures noted above, “partialists” only care for one aspect of a person’s health. Thus, an individual’s care is not only spreading among many providers, increasing fragmentation, but dramatically increases cost by multiple subspecialist referrals for conditions (“I’m a cardiologist; I do hearts. If your knee hurts, see an orthopedist”). The specialty of primary care (I am aghast that Gruber is inane enough to contrast “primary care provider” and “specialist”) provides care for the whole person. Rather than managing a single condition or organ system, the primary care provider manages many chronic diseases, sometimes with help from consultants whose recommendations s/he has to coordinate and rationalize in his/her role as the primary consultant to the patient. S/he also cares for acute problems. And provides preventive care, counseling and screening. And understands the impact of the family and community of each person, and on their health and their ability to address their health needs. And “asks for trouble”, even when the patient doesn’t complain of a problem (“Are you feeling safe at home?). And, most importantly, recognizes that the role of primary consultant to the patient means working hard to understand the patient’s world-view, to speak their language, and realize that “knowing the right answer” is absolutely meaningless unless it can be translated into health benefit for the patient. This is a skill set that is exceedingly complex, difficult to develop and maintain, and requires the highest level of cognitive and interpersonal skills, and requires constantl improvement over time. In Gruber’s Massachusetts, health reform has been stymied by the insufficient number of primary care providers to care for all the newly-insured despite a wealth of subspecialist / partialists. His comments implying the simplicity of primary care do nothing to advance the quality of health care to our population, which is after all the goal of health reform -- not coverage but access to high quality care for all.

Beyond these issues with primary care, Gruber’s analysis is fatally flawed in its assumption that expanding insurance coverage – with the government paying for it – is the solution to universal coverage. He only tangentially addresses the issue once, saying “Other countries, such as the Netherlands and Switzerland, have demonstrated that it is possible to have both universal coverage (even coverage provided through private insurance companies) and much lower health care spending.” As clearly noted in T.R. Reid’s “Frontline” piece “Sick around the world”,[2] Switzerland’s insurance companies are – and were even before universal coverage – not for profit. This makes a tremendous difference.

To suggest that we should have universal coverage paid for by the government through for-profit insurance companies, is exactly equivalent to giving enormous government bailouts to the financial sector that they can use to pay stockholder dividends and executive bonuses! (Whoops, we did that!) It is absolutely wrong and misguided. It is morally and logically bankrupt, and, ultimately, financially bankrupting.